SBAR Report: Managing a Patient with Cerebrovascular Accident (CVA)

QUESTION

SBAR report (6 points)

Situation

Background

Assessment

Recommendation ?

 

Situation

The patient is 51-year-old male is admitted for CVA. The residents admitted diagnosed hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.  He was brought to the rehab facility after having a hospital visit due to a brain blood clot that occurred at a bar while drinking with friends. Patient stated he experienced his hand moving on its own, without him making an effort to move it. Patient lives alone. He has no family around. He is allergic to NSAIDs. The patient is full and his diet is regular thin texture liquid. Patient has no prior surgery. The patient have behavior issues, appear to be easily agitated, and difficult to communicate with related to his care. The doctor requested that the patient’s blood sugar be checked frequently.
Background

Hypertension, protein calorie malnutrition, vitamin B12 deficiency, body mass index (BMI) 44.9 adult, muscle weakness (generalized) and chronic kidney disease stage three.

The residence has no prior surgery.

 

Objective data

current vital sign temp 97.5 F, Pulse 98, R 18, BP 130/88, O2 saturation, 97%, blood glucose 124, patient started level is at 8/10 on a scale of 0/10. Patient creatinine level is high 1.9 mg/dL. Glasgow coma score 15, no facial drooping, good skin turgor. tremor on the right hand. Impaired mobility, Patient uses a 2 front wheel walker and cane. Patient appears not well groomed, redness on his lower abdomen.

 

Subjective data

Patient states he is allergic to NSAIDs, lives alone, and stated once he gets discharged, a caregiver will  help take care of him. The patient also mentions from time to time he has a sudden headache, loses balance and has an occasional accident in his underwear (loose stool).

 

Recommendation ?

 

Expected patient outcomes/goals for the shift written as SMART goals.

Specific

Measurable

Achievable

Relevant

Time-bound

Analyzing Cues (5 points)

What assessment data collected relates to the client’s condition or history? List specific data collected during your head to toe assessment.  DO NOT list diagnoses here.  (4 points)

Which portions of your assessment are more concerning than others? (1 point)

 

Prioritize Hypotheses (5 points)

Using the assessment data collected, what are your three main concerns with this patient’s condition? These should be written as nursing diagnoses. (5 points)

Generate Solutions (6 points)

Identify three nursing interventions that will help achieve each of the priority outcomes you identified above.

(3 priority outcomes and 3 specific actions per outcome) (6 points)

Take Action 

Which of the nursing interventions you stated will address the highest priority for your patient and how? (5 points)

 

Evaluate Outcomes (9 points)
Evaluate actual client outcomes and compare to expected outcomes. (4 points)

Which assessment findings indicate improvement in condition? (1 point)

Which assessment findings show no improvement in patient’s condition? (1 point)

If patient outcomes were not achieved, what are the next two steps you would take? (3 points)

 

Reason for needing healthcare? (medical diagnosis/surgical procedure)?

What are the patient Priority assessments?

State key problem number one?

Assessment data?

Interventions?

 

State key problem number two?

Assessment data?

Interventions?
State key problem number tree?

Assessment data?

Interventions?

 

State key problem number four?

Assessment data?

Interventions?
State key problem number five?

Assessment data?

Interventions?

ANSWER

SBAR Report: Managing a Patient with Cerebrovascular Accident (CVA)

Situation

A 51-year-old male is admitted for CVA and diagnosed with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The patient has a history of hypertension, protein-calorie malnutrition, vitamin B12 deficiency, BMI of 44.9 (indicating obesity), chronic kidney disease stage three, and muscle weakness. He was brought to the rehab facility after experiencing a brain blood clot while drinking at a bar. The patient lives alone and has no family support. He is allergic to NSAIDs, and his diet is regular thin texture liquid. The patient experiences behavioral issues and agitation, making communication challenging. Frequent blood sugar monitoring is requested by the doctor.

Background:
Hypertension, protein-calorie malnutrition, vitamin B12 deficiency, BMI 44.9 (obesity), chronic kidney disease stage three.

Objective Data:
Current vital signs: Temperature 97.5 F, Pulse 98, Respiratory rate 18, BP 130/88, O2 saturation 97%, blood glucose 124 mg/dL, patient pain level 8/10, creatinine level 1.9 mg/dL, Glasgow coma score 15, no facial drooping, good skin turgor, right-hand tremor, impaired mobility with a 2 front wheel walker and cane, patient appears not well-groomed, redness on the lower abdomen.

Subjective Data:
Patient is allergic to NSAIDs, lives alone, and plans to have a caregiver after discharge. He experiences sudden headaches, balance issues, and occasional loose stool accidents.

Recommendation

Expected Patient Outcomes/Goals for the Shift:

Specific: Monitor and maintain blood glucose levels within the target range.
Measurable: Blood glucose levels within 80-180 mg/dL.
Achievable: Frequent blood sugar monitoring and appropriate insulin administration.
Relevant: To prevent complications and promote healing and recovery.
Time-bound: Throughout the shift.

Specific: Promote mobility and reduce tremor in the right hand.
Measurable: Improved ability to ambulate and decreased hand tremor.
Achievable: Encouraging regular physical therapy sessions and medications.
Relevant: Enhancing the patient’s independence and quality of life.
Time-bound: Throughout the shift.

Specific: Monitor for skin integrity and manage redness on the lower abdomen.
Measurable: Improved skin condition and reduced redness.
Achievable: Regular skin assessments and appropriate wound care.
Relevant: Prevent pressure injuries and potential complications.
Time-bound: Throughout the shift.

Analyzing Cues:
The assessment data collected during the head-to-toe assessment include vital signs, blood glucose levels, pain level, creatinine level, Glasgow coma score, presence of tremor, mobility status, and skin condition.

The most concerning aspects are the elevated blood glucose levels, impaired mobility, and behavioral issues, which may indicate potential complications and hinder the patient’s recovery.

Prioritize Hypotheses:
Impaired physical mobility related to hemiplegia and hemiparesis.
Risk for ineffective tissue perfusion related to hypertension and chronic kidney disease.
Risk for imbalanced nutrition: less than body requirements related to protein-calorie malnutrition and vitamin B12 deficiency.

Generate Solutions:
Encourage and assist with regular physical therapy sessions to improve mobility.
Administer antihypertensive medications as prescribed to manage blood pressure.
Collaborate with the dietitian to develop a personalized nutrition plan to meet the patient’s nutritional needs.

Take Action:
The highest priority nursing intervention is to encourage and assist with regular physical therapy sessions to improve mobility. Mobility is essential for the patient’s recovery and preventing complications such as pressure injuries and muscle contractures.

Evaluate Outcomes

Actual client outcomes:
Blood glucose levels remain within the target range (80-180 mg/dL).
Improved mobility with reduced hand tremor.
Improved skin condition with reduced redness.

Assessment findings indicating improvement:
Blood glucose levels within the target range.
Improved mobility and reduced hand tremor.
Improved skin condition and reduced redness.

Assessment findings showing no improvement
None reported.

If patient outcomes were not achieved, the next steps would be to reassess the interventions, modify the plan of care, and involve a multidisciplinary team to address any barriers to achieving the desired outcomes.

Conclusion

The SBAR report highlights the management of a patient with CVA and emphasizes the importance of prioritizing nursing interventions based on assessment data. By focusing on blood glucose control, mobility improvement, and skin integrity, nurses can play a crucial role in promoting positive patient outcomes and enhancing overall well-being. Collaborative care and evidence-based practice are key to addressing the patient’s complex health needs effectively.